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Boarding Registration Form
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This field is for validation purposes and should be left unchanged.
This form does NOT act as a boarding reservation, this form allows our team to have the required information before your pets stay! *FOR MULTIPLE PETS – WE REQUIRE AN AGREEMENT FORM PER PET*
Client Information
Are you a current client of Bedford Veterinary Medical Center?
(Required)
Select One
Yes
No
Owner Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
(Required)
Phone
(Required)
Phone Number - list any additional number we can reach you at:
(Required)
What is the best way to reach you while your pet is staying with us?
(Required)
Phone
Text (if you provided a cell phone number only)
Email
I will not be reachable, please use my emergency contact
Emergency Contact
Must be able to make medical decisions if you are not reachable.
Owner Name
(Required)
First
Last
Emergency Contact Phone
(Required)
Relationship to Owner
(Required)
Pet Information
ONLY ONE PET PER AGREEMENT FORM
Pet's Name
(Required)
Is your pet current on vaccinations? Canine: Rabies, Distemper, Kennel Cough, HW Test Feline: Rabies, Distemper
(Required)
Select One
Yes
No
Current Heartworm Prevention Product (required for boarding):
(Required)
Please List Name and Last Date Given
Current Flea & Tick Prevention Product (required for boarding):
(Required)
Please List Name and Last Date Given
Has your pet had a negative fecal exam in the past 6 months?*
(Required)
Select One
Yes
No
Has your pet been to another boarding or daycare facility within the past two weeks?
(Required)
Select One
Yes
No
If Yes, which facility?
(Required)
Feeding Information
Please fill out feeding information below.
Please provide all dry food in indiviudal ziploc bags labeled with your pets name, the date food is provided for, and AM, MIDDAY or PM as required for the entirety that your is staying with us. Please label all canned food with your pets name, frequency and amount to feed on the front of the can.
If you forget your pets food, we can provide you with a small bag of prescription bland house diet for an additional charge of the cost of the diet (usually $35-50 per 6-8pound bag).
Note: We are unable to take in large bags of pet food - thank you for your cooperation!
Will you be providing your pet's food for their stay?
(Required)
Select One
Yes
No
Name of Food:
(Required)
How many times/day?
(Required)
How much at each feeding?
(Required)
Please list any additional information we should know about feeding your pet:
(Required)
If none, please type N/A
Medication & Instructions
(Required)
If none, please type N/A
I understand all medications must be brought in their original labeled bottles and/or packaging.
(Required)
Initial Here
Drop Off & Pick Up
Which date(s) are you looking to board?
(Required)
Drop Off Time
(Required)
2:30pm (weekends only)
3pm
3:30pm
4pm
4:30pm
5pm (weekday only)
MUST be between 3pm-5pm
Pick Up Time
(Required)
8am (weekday only)
8:30am
9am
9:30am
10am
10:30am (weekends only)
MUST be between 8am-10:30am
Would you like your dog to do play and stay if there is availability?
(Required)
Select One
Yes
No
If Yes, how many times:
If none, please type 'N/A'
Has your pet passed the LRVC/BVMC Daycare evaluation prior to boarding?
(Required)
Select One
Yes
No
If your pet requires basic medical attention while in our care (example: anxiety, ear infection, hot spot, skin abrasions, upset stomach causing vomiting and/or diarrhea, etc.)- do you authorize treatment?
(Required)
Select One
Yes, please provide basic medical treatment for my pet. I understand I am responsible for the cost. (Not to exceed $150 without your authorization.
No, please contact me at the listed method above before providing treatment to my pet. I understand if no contact is made, treatment will be determined by the Veterinarian on duty.
NOTE: If we do not hear back from you within 4 hours we will proceed as recommended by the Veterinarian on duty. We will always contact you as soon as possible for any urgent or emergency medical situations.
I understand if my pet is not picked up by 10am or is dropped off before 3pm, an additional day of boarding may be charged.
(Required)
Initial Here
I understand if my pet displays unpredictable and/or aggressive behavior towards any Animal Care Coordinators, I am required to make arrangements for my pet to be picked up immediately.
(Required)
Initial Here
By signing your name, you agree to the terms below:
⦁ Reasonable precaution will be used against injury, escape, or death of said animal.
⦁ I understand that any additional items such as bowls, toys or bedding should be left at home unless approved ahead of time.
⦁ I understand that if my pet is due for any required vaccines or prevention while during their stay, or found to be overdue for required vaccines, I will be responsible for the cost.
⦁ I understand that any medical problem that develops with my pet and I am not reachable within 4 hours, my pet will be treated as deemed best by the veterinarians on duty and I assume full responsibility for the treatment expense involved.
⦁ The clinic and staff will not be held liable for problems that develop provided reasonable care and precautions are followed.
⦁ I have confirmed that all my contact information listed above is accurate.
⦁ I understand that my pet is to be dropped off and picked up during the listed hours only or an additional fee may apply.
⦁ I understand that no one is here overnight to supervise my pets.
I am at least 18 years of age.
Consent
(Required)
I agree to the below financial policy
Payment is due at time of service. Forms of payment accepted include cash, all major credit cards, Care Credit, and Scratchpay. Checks are not accepted.
Consent
(Required)
I agree to the below policy
I, the undersigned, certify that I am 18 years of age or older and I am the legal owner (or authorized agent of the owner) of the patient listed above. I agree to assume financial responsibility for all charges incurred and agree to pay such charges at the time of services rendered. I also understand that personal checks are not accepted. I am responsible for all interest and collection fees on any unpaid balance, as well as reasonable attorney fees and court costs associated with collection of unpaid balances. I acknowledge that the above information is true and accurate to the best of my knowledge.
Bedford Veterinary Medical Center (BVMC) is an ABUSE-FREE WORKPLACE. By initialing here, I understand that BVMC has a ZERO TOLERANCE policy for profanity and verbal abuse. I further understand that any profane, abusive, or hostile behavior or language directed at any member of the BVMC team will result in immediate removal from the hospital, and I will no longer be allowed to bring any of my pets to BVMC in the future, for any reason.
Authorization Signature
(Required)
First Name
Last Name
Email Consent
I agree to receive email communications.
I agree to receive marketing offers and updates via your preferred/primary email. You'll still receive services and account related emails if you do not check the box.
SMS Consent
I agree to receive SMS communications.
I agree to receive recurring automated messages about pet care, appointment reminders, marketing communications, and offers to the mobile number provided. Your consent is not required, and you may opt out at any time by replying STOP. Msg & data rates may apply. Message frequency may vary.
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